The relation between self-efficacy and cognitive/physiological self-

In order to investigate whether neurofeedback training indeed increased self- efficacy, paired t-tests were computed to compare the scores at baseline and post assessment. The increase in TCQ (t(15) = -1.851, p = .084; Figure 7.1A) and TCAQ score (t(15) = -1.867, p = .082; Figure 7.1B) only just failed to reach significance. The increase in SES was highly significant (t(15) = -4.374, p = .001; Figure 7.1C).

Figure 7.1. A-B) Improvements in TCQ and TCAQ scores after a course of five neurofeedback sessions only just failed to reach significance, C) while the improvement on the SES was highly significant.

If a higher up-regulation ability is related to a higher sense of self-efficacy, then Bandura’s self-efficacy theory would predict that patients who perform well on the neurofeedback task will have lower depression severity scores. In accordance, a significant negative correlation was found between neurofeedback ability and ‘DepressionTotal’ at post assessment (r = -.508, p = .045; Figure 7.2). Conversely, no significant correlation was found between up- regulation performance on the one hand and TCQ (p = .74), TCAQ (p = .688), and SES (p = .875) score at post assessment on the other. This finding does not necessarily go against the predictions made by self-efficacy theory, as the theory stresses the importance of perceived self-efficacy (opposed to actual self-regulation skills). Therefore, the potential relation between depression severity and the self-efficacy measures was investigated next.

At baseline, no correlations were found between ‘DepressionTotal’ on the one hand and TCQ and SES on the other (both ps > .5). However, a significant negative correlation was found between ‘DepressionTotal’ and TCAQ at baseline (r = -.542, p = .03; Figure 7.3) and after five neurofeedback sessions (r = -.665, p = .005; Figure 7.4). It must be taken into account that these significant findings might not reflect a true correlation between ‘DepressionTotal’ and TCAQ and instead may be a consequence of the multiple comparisons conducted, which inflate type I errors. The data points below the dashed line in Figure 7.3 and 7.4 represent the same four patients on both graphs. This might suggest that neurofeedback training induces little change if patients have a relatively high initial depression score combined with a relatively low initial TCAQ score.

Figure 7.2. Relation between depression severity and up-regulation performance at post assessment. Each data point represents a patient. DepressionTotal represents the aggregate score computed from the BDI and HADS questionnaire.

-3 -2 -1 0 1 2 3 4 5 6 -4 -3 -2 -1 0 1 2 3 4 Sel f- regul at io n abil it y (t -st at ist ic) DepressionTotal

Post assessment

Figure 7.3. Relation between depression severity and perceived self-efficacy of thought control at baseline. Each data point represents a patient. DepressionTotal represents the aggregate score computed from the BDI and HADS questionnaire.

Figure 7.4. Relation between depression severity and perceived self-efficacy of thought control at post assessment. Each data point represents a patient. DepressionTotal represents the aggregate score computed from the BDI and HADS questionnaire.

20 30 40 50 60 70 80 90 -4 -3 -2 -1 0 1 2 3 4 TC AQ DepressionTotal

Baseline assessment

Post assessment

A one-sample t-test showed that there was a significant decrease in the Total Mood Disturbance (TMD) scores, derived from the POMS, after each neurofeedback session (t(63) = -4.731, p < .001). For none of the four neurofeedback sessions a correlation between change on the POMS and the presented reward rate was found (all ps > .7). A significant drop in TMD scores was also found during the transfer session (t(15) = -3.993, p = .001). These two findings suggest that the presentation of positive feedback on its own does not induce mood improvements and is unlikely to result in specific improvements in depression.

7.5 Discussion

Our data suggest that neurofeedback training induces a higher sense of self- efficacy. Self-efficacy theory predicts that as a consequence patients may expect to be more successful in controlling their thoughts and are therefore more likely to attempt to do so. It must be noted that patients who had a relatively high depression score in combination with a relatively low perceived thought control ability score at baseline seemed to benefit little from the neurofeedback procedure. This suggests that an initial amount of perceived self- efficacy of thought control might be required to generate more self-efficacy confidence in the long term and to improve depression. Therefore, it might be of interest to investigate whether neurofeedback can play a preventative role in the development of depression. It should be noted that the current study does not allow making any inferences of causality as it could be that improvements in mood, as indicated by the POMS, resulted in patients feeling more adequate in controlling their cognitions.

No significant correlation was found between any of the self-efficacy measures and up-regulation performance at post assessment. As self-efficacy theory predicts, this suggests that there is an important distinction between perceived self-efficacy, as measured by for instance the TCAQ, and actual self-regulation skills as measured by up-regulation ability. However, patients who performed

better on the neurofeedback task did tend to have lower depression scores at post assessment. It is not clear what mediates this relation. The role of the specific neurobiological component targeted by neurofeedback is still unclear as this analysis had to be collapsed across group.

The neurofeedback training seemed to induce relatively direct improvements in mood, as significantly lower TMD scores were obtained after each neurofeedback run. It is unlikely that the presented feedback induced these mood changes by being experienced as rewarding, as no correlation between reward rate and TMD score was found. The reason why patients experienced a positive improvement in mood during the transfer session remains elusive. Patients did not manage to up-regulate their target area during this session (see section 5.4) and were not presented with any feedback that could have installed a sense of self-regulation mastery. It is doubtful that patients experienced relief after leaving the relatively confined and noisy environment of the scanner as none of the patients, apart from one drop out, reported any discomfort. It could be possible that the mere completing of a session made patients feel better about themselves or that the imagery of either positive emotions or relaxing environments left patients feeling less disturbed.

Although issues surrounding multiple testing were prevented as much as possible by executing data reduction steps wherever appropriate, the current analysis may still suffer from inflated type I errors. As a consequence the results should be interpreted with caution but are nevertheless of interest in this exploratory analysis.